Abnormal Neurologic SOAP Note

Abnormal Neurologic SOAP Note

Develop a SOAP note for a patient you encountered who had an abnormal neurologic presentation. You must use clinical practice guidelines in your post.

Abnormal Neurologic Presentation

Soap Note: Multiple Sclerosis

Multiple sclerosis is a chronic, demyelinating, and disabling disease of the central nervous system that initiates among young adults. The neurological condition is characterized by the inflammatory demyelination over numerous locations and episodes in the CNS.

Subjective Data

Chief Complaint: The patient presents with complaints of recurrent episodes of weakness, visual changes, fatigue, numbness, loss of balance, and tingling sensations in some parts of her body.

History of Present Illness: Mrs XY is a 30-year-old female patient who presented to the Neurology Clinic for assessment of long-term neurological complaints. She states that for many years she has noticed major changes in her neurological functions, mainly heat intolerance precipitating her difficulty in gait, impaired balance, and a tendency for falling. Also, her visual acuity has appeared to change sporadically in the last five years. Last month, the patient was working hard at the office and was under immense stress. Her neurologic condition deteriorated after she had a flu attack. At the time, the patient could not hold any objects in her hands as she had tremors and fatigue, which led to nasty falls. Since then, she has been experiencing arthralgia on the right side and consequently, on the left side. The patient states she first began noticing the symptoms about one week ago. Since then, she has been feeling increasingly worse. The aggravating factors include hot weather and stress at work while the easing factors are cold weather and resting. Today, the patient is experiencing multiple problems as she is feeling weak and has numbness on the right side. Also, she has nocturia and impaired urinary bladder function that necessitates several voids.  She is extremely fatigued and has been having persistent balance problems with a spinning sensation.

Past Medical History: Depression and anemia

Allergies: None known to patient

Current medications: Vitamin C 500mg, Alysse, and Tylenol

Family history: Both parents are alive and healthy

Surgical history: Caesarean section 5 years ago

Social history: Former smoker, quit seven years ago and social drinker with about 2 alcoholic beverages weekly.

Review of Systems: significant for several problems associated with suspected multiple sclerosis. She has the tendency to aspirate solids and liquids. She complains of irritability, impaired short-term memory, and tinnitus that is continuous and related with hearing loss and prominence on the left. The patient has declined dexterity in her fingers and weakness of both hands bilaterally.

Objective

Physical Examination

Vital signs: 37⁰ Celsius (Temperature), 18 (Respiratory rate), 60 (Pulse), O₂saturation: 99% room air, 108/76 (Blood pressure), weight: 135 lbs, height 5′ 6″– BMI: 21.8

General:  Alert, oriented x 4 situation, person, time, and place, gait and balance disturbance

HEENT: Internuclear ophthalmoplegia, equal, round, & reactive pupils, difficulty adducting in lateral gaze, optic neuritis, white matter MRI lesions, diplopia, nystagmus, abnormal extra-ocular movements, hearing loss, and facial pain

Skin: Normal skin examination clear no rashes or lesions

Lungs: Normal pulmonary examination, clear all fields, regular, unlabored respirations

Heart: Normal cardiovascular examination, S1, S2 regular heart sounds

Abdomen: Normal abdominal examination, soft, active bowel sounds, and non-tender

Genitourinary: Urinary incontinence, frequency, clear and yellow urine no foul odour

Neuromuscular: Positive Trendelenburg’s sign, Lhermitte’s sign, spasticity, dysmetria, hyperreflexia, positive babinski, proximal muscle weakness bilaterally, bilateral sensory loss in lower extremity, tremor, abnormal gait

Extremities: Muscle spasms, tremors, and weakness

Assessment

Problem List

1. Fatigue affecting quality of life
2. Lower limb weakness presenting as hemiparesis that impairs functional mobility
3. Impaired coordination impacting ADLs

Diagnosis: Multiple sclerosis (laboratory support)

Differentials: 

1. Gliomas and lymphomas of hemispheres, brainstem, and spinal cord
2. Collagen vascular disease -systemic lupus erythematosus
3. Lyme disease
4. Behçet’s disease
5. Lyme disease
6. Sarcoidosis

Plan

The management principles comprise three main goals: delaying the disease progression, managing chronic symptoms, and treating acute exacerbations. At present, MS has no known cure. The therapeutic regimens can either be disease-specific or symptomatic (immunomodulatory or immunosuppressive). The glucocorticoids are used in treating acute exacerbations as they both have anti-inflammatory and immunomodulatory effects that restoration of the blood-brain barrier, reduction of edema, and improvement of axonal conduction. When the exacerbation symptoms are acute to necessitate treatment, depo-Medrol with an oral prednisone taper could be administered. Also, plasma exchange therapy provides benefits to patients and is considered in the refractory severe relapsing MS. Once the suitable drug therapy is stabilized, the physician monitors the patient as more often as symptoms appear to evaluate the functioning level and medication effectiveness, and adjust dosages. Also, the patient can be referred to a neurosurgeon for extreme spasticity. Finally, the patient should be educated in all facets of the disease, diet, medication, adverse effects, health complications, disease progression, management of fatigue, and pain.

 References

Bickley, L. S., Szilagyi, P. G., In Hoffman, R. M., & Bates, B. (2017). Bates’ pocket guide to physical examination and history taking. Philadelphia: Lippincott Williams & Wilkins.

Dunphy, L. M. H., In Winland-Brown, J. E., In Porter, B. O., & In Thomas, D. J. (2019). Primary care: The art and science of advanced practice nursing – an interprofessional approach. Philadelphia, PA: F.A. Davis Company.

Seller, R. H., & Symons, A. B. (2017). Differential Diagnosis of Common Complaints. Philadelphia, Pa, Elsevier/Saunders.